I want to make a difference in the lives of patients at the Lemuel Shattuck Hospital by supporting Partners in Life, Inc. with a monetary gift.

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Donor Name

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Address1

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Address2

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City                                                                        State                                                       Zip        

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Day Phone                                                                           E-mail Address

Amount of Contribution:

___ $25     ___ $50     ___ $100      ___ $200     ___ $500     ___ Other $_____________

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Name(s) as should appear in Donor Honor Roll

___  I wish for my gift to be listed as “Anonymous”

 ___ My gift is in honor / memory (circle one) of:  ______________________________________

Please notify the following individual(s) of this gift (name & address):

Name(s) ___________________________________________________________________________

Address: ___________________________________________________________________________

City, State, Zip: _____________________________________________________________________

Please return completed form and your check to:

Partners in Life, Inc. c/o Lemuel Shattuck Hospital , 170 Morton Street , Jamaica Plain , MA 02130

THANK YOU FOR YOUR TAX DEDUCTIBLE GIFT!

A receipt will be forwarded to you at the address you provided above.